Elevate Orthodontics - New Patient Forms

New Orthodontic Treatment Start

Congratulations on starting your orthodontic treatment journey! Please review and complete the form to begin your journey to a happy, healthy, confident smile. If you have any questions, please contact our office.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Legal Guardian Full Name (if patient is a minor)

First NameLast Name

Authorization to Release Account Information
This form is to acknowledge that I First Name Last Name , hereby authorize First Name Last Name to have access to all information relevant to patient of record's # Account Number treatment as outlined below. I understand that giving this authorization allows the below person(s) to receive information, while I am still responsible for this account. I understand that I have the right to retract this consent at any time by providing Elevate Orthodontics a written notice. By granting this access, I am acknowledging that I am a responsible party of the patient of record listed above and have the legal right to give access to financial and/or treatment information the below individual(s).
Additional Individual #1 with access:
Information to share with Individual #1:

FinancialTreatment
Additional Individual #2 with access:
Information to share with Individual #2:

FinancialTreatment
Additional Individual #3 with access:
Information to share with Individual #3:

FinancialTreatment
Additional Individual #4 with access:
Information to share with Individual #4:

FinancialTreatment
Responsible Party Giving Consent Name

First NameLast Name
Responsible Party Giving Consent Phone Number
Please enter a valid phone number.
Responsible Party Giving Consent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Responsible Party Signature*

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Media Consent and Release

Photos and other digital media that reflect your treatment success and positive experience can help future patients decide that Elevate Orthodontics is the right choice for their orthodontic care.
Authorization to release orthodontic treatment information*

I hereby consent to Elevate Orthodontics’ and its affiliates’ use of photographs and media related to my/my minor child’s treatment, along with details regarding the related dental services, for marketing and advertising purposes. This consent form is optional and I understand that Elevate Orthodontics will not condition treatment on whether I sign this authorization form. I authorize Elevate Orthodontics and its affiliates to use photograph(s), video(s), and/or media representation(s) (whether such material was provided by me or produced by Elevate Orthodontics) related to my or my minor child’s care. I understand that these materials might be used in advertisements, office displays, online (e.g., websites, Facebook, Instagram, etc.), and in any other format that Elevate Orthodontics chooses. I release the photographer, Elevate Orthodontics, their affiliates, employees, agents, and designees from liability for any violation of any personal or proprietary right I or the patient may have in connection with such use. I waive any rights to inspect or approve promotional materials which include these materials related to my treatment. This authorization shall expire upon completion of all Elevate Orthodontics' promotional activities. I understand that I may revoke this authorization by sending a written request for revocation to Elevate Orthodontics’ Privacy Officer. If I revoke this authorization, Elevate Orthodontics will no longer use or disclose my medical information for the reasons covered by this authorization, except to the extent it has already relied upon this authorization (for example, if my photographs are already being used in an ongoing advertising campaign). I understand that when Elevate Orthodontics discloses information pursuant to this authorization, the information may no longer be protected by federal or state privacy rules and may be subject to re-disclosure by the recipient of the information.I do not consent to the use of these materials of myself or the listed patient.
Signature*

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AAO Informed Consent for the Orthodontic Patient

Risks and Limitations of Orthodontic Treatment
Please read and acknowledge the following form from the Amercian Association of Orthodontists (AAO) prior to starting your treatment. The signature below this form is required.
Acknowledgement of AAO Informed Consent

I, the undersigned patient (or parent/guardian if the patient is a minor), have reviewed a copy of the AAO Informed Consent and acknowledge my understanding and consent to treatment.
Signature

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Assignment of Benefits Authorization
I, First Name Last Name, the policy holder, do hereby instruct the company named below to make payment directly to the address provided on the claim form.

This authorization is for the benefits otherwise payable to me under my current insurance policy. I also authorize the release of any information pertinent to my case to any insurance company, other doctor’s office, or attorney involved in this case. A photocopy of this assignment shall be considered as effective and valid as the original.

This authorization and assignment shall be irrevocable for the full extent of the patient’s treatment by said practice, until such time that the patient’s expenses
incurred have been paid in full.

To assist us in generating an accurate estimate at your consultation, please complete the following section prior to your scheduled exam and consultation. Please also bring your insurance card to your appointment and present it to our appointment coordinators when you arrive.
Policy Holder Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Holder Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Policy Holder SSN or ID#
Group ID#
Employer Name
Insurance Company Name
Insurance Company Street Address or PO Box #

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone Number
Please enter a valid phone number.
Patient Name (if different from policy holder)

First NameLast Name
Policy Holder Party Signature*

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Authorization to Release Financial Account Information
This form is to acknowledge that I First Name Last Name, herby authorize First Name Last Name to have all financial information on my account #Account Number at Elevate Orthodontics. I understand that giving this authorization allows the above person(s) to make payments on my account and to have access to all financial information. By allowing this release of information, I do understand that I am still solely responsible for this account. I understand that I have the right to retract this consent at any time by providing Elevate Orthodontics a written notice.
Responsible Party Giving Consent Name

First NameLast Name
Responsible Party Giving Consent Phone Number
Please enter a valid phone number.
Responsible Party Giving Consent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Responsible Party Signature*

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Authorization to Release Orthodontic Treatment Information
This form is to acknowledge that I First Name Last Name, herby authorize First Name Last Name to have all orthodontic treatment information on patient First Name Last Name at Elevate Orthodontics. I understand that giving this authorization allows the above person(s) to make appointments onFirst Name Last Name account and to have access to all orthodontic treatment information only. By allowing this release of information, I do understand that I am still solely financially responsible for this account. I understand that I have the right to retract this consent at any time by providing Elevate Orthodontics a written notice.
Responsible Party Giving Consent Name

First NameLast Name
Responsible Party Giving Consent Phone Number
Please enter a valid phone number.
Responsible Party Giving Consent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Responsible Party Signature*

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Should be Empty:

New Orthodontic Treatment Start

Authorization to Release Account Information

Media Consent and Release

AAO Informed Consent for the Orthodontic Patient

Acknowledgement of AAO Informed Consent

Assignment of Benefits Authorization

Authorization to Release Financial Account Information

Authorization to Release Orthodontic Treatment Information